The histiocytoses of childhood

Choroidal Mass in a Patient with Undiagnosed Pulmonary Langerhans' Cell Histiocytosis

BACKGROUND

Langerhan cell histiocytosis (LCH), although not a common cause, should be kept in the differential diagnosis for a patient that presents with a choroidal mass.

CASE PRESENTATION

A 28-year-old female presented with a 4-day history of vision loss and associated pain in her right eye.

EXAMINATION AND INVESTIGATIONS

A dilated fundus examination revealed a deep subretinal, orange, mottled lesion with associated serous retinal detachment. Ultrasonography demonstrated a solid mass at the posterior pole. Fluorescein angiography revealed corresponding, small, punctate, hyperfluorescent areas with leakage and pooling in the late phase outlining the subretinal fluid. Optical coherence tomography confirmed the choroidal elevation and subretinal fluid. In addition to starting oral steroids for addressing the patient's acute symptoms, a metastatic workup was ordered due to the lesion's appearance. Diagnosis: Computed tomography (CT) of the chest showed nodular lesions and subsequent lung biopsy was S-100 and CD1a positive, diagnostic of Langerhan's cell histiocytosis (LCH).

TREATMENT AND OUTCOME

The patient was treated with six cycles of vinblastine and prednisolone therapy followed with a subsequent taper of steroids. Complete resolution of signs and symptoms was noted.

DISCUSSION

A review of all reported cases of ophthalmic LCH with or without choroidal involvement was conducted. Diagnostic and therapeutic approaches described in these reportshave been summarized in the current manuscript. This case highlights the importance of pursuing a systemic workup in patients with uveal mass lesions. LCH should be considered in the differential of every choroidal mass.

Clinical spectrum and management outcomes of Langerhans cell histiocytosis of the orbit

Purpose

To describe the clinical spectrum and management outcomes of Langerhans cell histiocytosis (LCH) involving the orbit.

Methods

Retrospective review of patients with orbital LCH presenting at the Sankara Nethralaya, Chennai, India, over the past 15 years. Demographic details, presenting features, radiology, histopathology, immunohistochemistry, and management outcomes were analyzed.

Results

Nine patients were reviewed. The mean age of presentation was 10.12 ± 14.31 years (range: 6 weeks to 35 years). Eyelid swelling was the most common presenting feature (4, 44.4%), followed by proptosis (3, 33.3%). The mean duration of the presentation was 2.21 ± 2.77 months. Radiological investigations revealed orbital roof osteolytic defects in six (66.6%) patients. Six patients underwent near-complete excision of the mass while three underwent incisional biopsy. Histopathology revealed histiocytes with nuclear grooving and numerous eosinophils characteristic of LCH. The cells were positive for CD1a and S 100 antigens. None of the patients had any systemic involvement. Three received systemic steroids and four received systemic chemotherapy. At a mean follow-up of 17.85 ± 23.46 months, all had complete remission without any signs of recurrence. One patient was lost to follow-up after near-complete excision while one adult patient with a mass in the intraconal space had no recurrence after near-complete excision.

Conclusion

LCH is a rare disorder of the orbit that commonly occurs in children and should be considered a differential for osteolytic lesions involving the orbit. All patients should undergo a systemic evaluation to rule out multifocal disease. The treatment depends upon disease extent and risk factors.

Cytological Diagnostic Approach in 3 Cases of Langerhans Cell Histiocytosis Presenting Primarily as a Thyroid Mass

BACKGROUND

Langerhans cell histiocytosis (LCH) is a monoclonal disease of specialised histiocytes characterised by the proliferation of neoplastic Langerhans cells (LCs) with a varying admixture of mature lymphocytes, eosinophils and plasma cells. LCH commonly occurs in the paediatric population and young adults with the involvement of bone, skin and lymph nodes. LCH has a protracted clinical course with an overall mortality rate of 3%. Primary involvement of the thyroid gland in LCH at presentation is a rare phenomenon that can result in misdiagnosis with consequent mismanagement.

CASE

Ultrasound-guided fine-needle aspiration cytology (FNAC) of the thyroid was performed in 3 cases at a tertiary cancer centre, including 2 referral cases where the patient presented with the only symptom of progressive thyroid enlargement. These cases were reported initially or on review and the results were correlated with histology/ancillary techniques. A cytological diagnosis of suspicion for LCH was offered in 2 cases at our centre and 1 case was referred to our centre with a diagnosis of suspected papillary thyroid carcinoma. On review of outside smears at our centre, the diagnosis was changed to suspected LCH. The diagnosis was confirmed by immunopositivity for CD68, CD1a and S100 in 1 case and Tru-cut biopsy followed by immunohistochemistry for CD1a, S100, TTF-1 and LCA in the other 2 cases.

CONCLUSION

FNAC was helpful in accurately diagnosing LCH even though the presentation was unusual. Thus, unnecessary surgery was obviated.

Orbital manifestations of Langerhans Cell Histiocytosis: A report of three cases

Langerhans Cell Histiocytosis (LCH) is a spectrum of disorders characterized by accumulation of histiocytes in various tissues. It is rarely encountered in ophthalmic practice and has an affinity for the orbit. We report three patients with LCH involving the lateral orbital wall, each with a different form of the condition.

Non-Langerhans cell histiocytosis with isolated CNS involvement: an unusual variant of Erdheim-Chester disease

Benign histiocytic proliferations are identified by their component cells and classified as either Langerhans cell histiocytosis or non-Langerhans cell histiocytosis. We report a 58-year-old Caucasian woman who presented with diabetes insipidus and was found to harbor a large suprasellar mass. Histopathological analysis was consistent with non-LCH. The differential diagnoses included juvenile xanthogranuloma, adult-onset xanthogranuloma, xanthoma disseminatum, Rosai-Dorfman disease, and Erdheim-Chester disease. Immunohistochemical examination demonstrated a proliferation of large lipid-laden histiocytic cells which were positive for CD68, negative for S100 protein, and showed only faint, background staining for CD1a. We present a case of an autopsy-confirmed non-Langerhans cell histiocytosis limited to the central nervous system and evaluated with both immunohistochemical and ultrastructural studies. Based on the multifocality, anatomic distribution, and immunostaining features, a diagnosis of Erdheim-Chester disease was made. This is only the second reported case of Erdheim-Chester disease with intracranial involvement but absence of extracerebral manifestations. Given the overlapping clinicopathologic, radiographic, and immunohistochemical profiles, differentiating between these rare histiocytic disorders can often present a significant diagnostic challenge. A systematic approach using all available clinical, laboratory, radiographic, histologic, immunohistochemical and ultrastructural data is essential for proper discrimination between the numerous histiocytoses.

Langerhans cell histiocytosis

The clinical manifestations of Langerhans cell histiocytosis have been recognized for more than a century. For most of that time, physicians have viewed the disease from different perspectives, interpreting portions of its clinical spectrum as if they were distinct and unrelated entities. More recently, Langerhans cell histiocytosis has been unified into a single concept, though the disease continues to defy traditional classification. By most accounts, Langerhans cell histiocytosis appears to be a morphologically benign proliferation of inflammatory cells that escapes regulatory control mechanisms. Studies from patients with all stages of the disease, however, document clonal proliferation of immune processing cells (i.e., Langerhans cells), suggesting a malignant disease process. The most common ophthalmic manifestation of Langerhans cell histiocytosis is a solitary lesion of orbital bone, which typically responds to minimally invasive therapy. The best management of solitary orbital Langerhans cell histiocytosis is debatable and has been complicated by its recent designation as a risk factor for central nervous system disease. This article summarizes recent developments in understanding the biology of Langerhans cell histiocytosis, reviews its ophthalmic manifestations, prognosis, and the controversy surrounding treatment of isolated orbital disease.

Ocular adnexal Langerhans cell histiocytosis clinical features and management

PURPOSE

To review the clinical features, investigations, management, and outcomes of Langerhans cell histiocytosis (LCH) with ocular adnexal involvement.

MATERIALS AND METHODS

Retrospective, non-comparative, chart review of 30 patients with LCH involving the ocular adnexa treated at 6 major Australian hospitals. Clinical features, imaging findings, treatment, local and distant recurrence and outcome were evaluated.

RESULTS

Twenty-four patients (80%) were male with a mean age of presentation of 9.5 years. Females presented at an earlier age (mean age 4.1 years) with more severe involvement. Eighty percent of the cases presented with periorbital swelling. Computed tomography usually showed destructive osteolytic lesions centred on the frontal bone. Twenty-four patients (80%) had unifocal, unisystem disease. From this group, none of 13 treated with excision alone had recurrence whereas 2 of 6 treated with excision followed by chemotherapy recurred.

CONCLUSIONS

Unifocal, unisystem LCH often presents to the ophthalmologist and can usually be diagnosed on clinical and imaging grounds. Computed tomography and magnetic resonance imaging are complementary imaging studies. Biopsy is essential to confirm diagnosis. Unifocal, unisystem disease can be treated with local excision and curettage. Incomplete excision, recurrent disease or multifocal disease may require systemic chemotherapy.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease (RDD) is a rare but well-defined histiocytic proliferative disorder of unknown etiology that usually presents with cervical lymphadenopathy, fever, leukocytosis, and hypergammaglobulinemia in an otherwise healthy child. Although many patients undergo spontaneous remission, a subset of patients with systemic disease has a more serious course. For those patients with a poor outcome, steroids and chemotherapeutic agents such as etoposide or 6-mercaptopurine plus low dose methotrexate have been used. We present a child with a massive cervical lymphadenopathy treated with 2-chlorodeoxyadenosine (2-CdA, cladribine) after other approaches failed.

Solitary cutaneous dendritic cell tumor in a child: Role of dendritic cell markers for the diagnosis of skin Langerhans cell histiocytosis

We describe a child with a solitary dendritic cell (DC) tumor positive for S-100 protein, CD1a, and HLA-DR with the clinical and histopathologic features of a so-called solitary variant of congenital self-healing Hashimoto-Pritzker reticulohistiocytosis (CSHRH). CSHRH is a spontaneously regressing, benign form of Langerhans cell histiocytosis (LCH) and was thought to be a histiocytosis consisting of precursor Langerhans cells. In our study the tumor cells did not express CD68, indicating that they represent mature DCs. Because of the negative finding for Langerin, it cannot be assessed whether the tumor consists of terminally mature Langerhans cells that have lost Langerin expression upon maturation or of mature dermal DCs. This case demonstrates that the progress in DC biology necessitates reevaluation of our knowledge of LCH to better understand the different variants of the disease. Therefore the literature on CSHRH is reviewed in light of present knowledge on cutaneous DC immunology.

A human Langerhans cell-like cell line, ELD-1, promotes CD8 T cells to produce IFN-γ through CD70-dependent alternative pathway

A novel pathway of CD8+ T-cell activation by a previously established human Langerhans cell (LC)-like cell line, ELD-1 [Dendritic Cells 9 (1999) 41] is reported. ELD-1 cells possess LC-specific and dendritic cell (DC) lineage-specific markers including Birbeck granules. Intriguingly, ELD-1 cells stimulated interferon (IFN)-gamma production by purified allogeneic CD8+ T cells in an IL-2- but not IL-12-dependent manner, but failed to stimulate CD4+ T cells due to their lack of HLA-DR, CD40, CD80, and CD86 expression. Comparing active and inactive subclones of ELD-1 cells revealed that CD70 was a key molecule determining stimulatory ability. This was confirmed by the ability of transfected CD70-encoding cDNA to confer stimulatory capacity on inactive subclones of ELD-1. Therefore, it is concluded that CD70 expressed on ELD-1 cells has a crucial role in stimulating IFN-gamma production by CD8+ T cells through an alternative pathway which does not require CD4+ T-cell help or CD28-B7 interactions.

Rosai--Dorfman disease with multi-organ involvement in head and neck region

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman, RD) disease is a well known entity. This pathology is differentiated from other childhood histiocytosis with its distinct features. Many sites within the head and neck area may be involved with the disease. Multi-organ involvement is very rare. A patient with Rosai-Dorfman disease involving neck, nose and larynx is presented and clinical follow-up is given.

Orbital xanthogranuloma: clinical and morphologic features in eight patients

PURPOSE

To describe the clinical and morphologic features of patients with orbital xanthogranuloma (XG) with or without Erdheim-Chester disease (E-Cd).

METHODS

Retrospective, noncomparative case series. A review of 8 consecutive histopathologically proven cases of orbital XG from 3 medical centers. Four male and four female patients with ages ranging from 23 to 79 years presented with 4 bilateral and 4 unilateral orbital XGs.

RESULTS

Age at diagnosis, ocular and systemic manifestations, histopathologic and radiologic features, type of treatment, and prognosis were evaluated for each patient. Six of 8 patients had proptosis and 2 presented with afferent pupillary defect and severe extraocular motility limitations. Other signs and symptoms included eyelid retraction, mechanical ptosis, and chemosis. Planar xanthomas of eyelids were present in 3 individuals. CT and MRI showed infiltrating soft tissue masses within the orbit in 7 and 2 patients, respectively. Histopathology revealed proliferation of foamy histiocytes intermingled with Touton and multinucleated giant cells and lymphocytes. The absence of Birbeck granules within the histiocytic elements of the tumor, indicating that the cell of origin is a non-Langerhans histiocyte, was documented with electron microscopy in 3 cases. The most common treatment was surgical excision combined with oral corticosteroids. Two patients with E-Cd with involvement of the long bones of the upper and lower extremities and retroperitoneal region died of kidney failure within approximately 1 year of diagnosis.

CONCLUSIONS

Orbital XG is a proliferative lesion of the non-Langerhans histiocytes, which may present as a solitary orbital lesion or may be associated with a systemic condition known as E-Cd with very poor prognosis.

Langerhans cell histiocytosis with periorbital cellulitis

PURPOSE

To report a case of Langerhans cell histiocytosis presenting as periorbital cellulitis.

DESIGN

Interventional case report.

METHODS

A 3-year-old girl presented with periorbital swelling of the right upper lid laterally of two days' duration. A history of recent eye trauma was reported.

RESULTS

Computed tomography showed a soft tissue mass that eroded the frontozygomatic suture. The lesion was debulked through a lateral orbitotomy. Electron microscopy disclosed Birbeck granules. Immunohistochemistry stained positively for CD68 and CD1a antigenic determinants.

CONCLUSIONS

Although rare, Langerhans cell histiocytosis can cause acute periorbital cellulitis in children. Trauma can induce an inflammatory response, allowing for earlier diagnosis of the orbital lesion.

A case of Rosai-Dorfman disease involving the lacrimal gland in an elderly patient

Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) is a rare disease characterised by benign proliferation of histiocytes, with painless lymph node enlargement and frequent extranodal involvement. Orbital involvement occurs in 11% of cases and onset of the disease is typically in the first two decades of life. A benign course is usual, but in some cases blindness or fatality may result. We present a case with late onset at age 78 years and lacrimal gland involvement, and review the literature on this disease.

Conjunctival necrobiotic granuloma in xeroderma pigmentosum

PURPOSE

We report clinical and histopathologic findings of a conjunctival lesion associated with xeroderma pigmentosum.

METHODS

A Saudi girl with known xeroderma pigmentosum presented with pain and photophobia of the right eye and an elevated temporally located perilimbal mass.

RESULTS

The mass was resected successfully and has not recurred during 1-year follow-up. Histopathologic examination of the tissue showed a necrobiotic granuloma with associated histiocytic infiltration. The patient had no systemic disease, lipid was not detected in the histiocytic lesion, no Touton giant cells were present, and there was no evidence of elastolysis.

CONCLUSION

Ocular malignancies occur in association with xeroderma pigmentosum, but benign lesions that mimic a malignancy may occur.

Langerhans cell histiocytosis involving the thyroid and parathyroid glands

Langerhans cell histiocytosis (LCH) is a rare illness, and the disease afflicting the thyroid gland is very uncommon, even in the presence of multisystem involvement. In this report, we document histologically, for the first time, concurrent involvement of the thyroid and parathyroid glands by LCH. A young Chinese woman with a history of diabetes insipidus and hypogonadism underwent a total thyroidectomy for enlarged thyroid gland secondary to LCH causing airway obstruction. Microscopic examination of the excised specimen disclosed CD1a- and S-100-positive LCH cells involving the thyroid and parathyroid glands. In a patient with LCH affecting the thyroid gland, parathyroid gland disease should be suspected when the serum calcium levels are depressed in association with an inappropriate serum parathyroid hormone level, such as a normal parathyroid hormone level in this case.

Expression of Fas ligand in Langerhans' cell histiocytosis: A case report of a boy with multisystem involvement

Previous reports of patients with Langerhans' cell histiocytosis have shown characteristics of osteolytic lesion, visceral involvement and organ dysfunction. We report a 2-year-old boy who was diagnosed as Langerhans' cell histiocytosis with a prominent hepatomegaly. X-Radiogram, computed tomography and magnetic resonance imaging revealed the osteolysis of the right iliac bone, the absence of the left eighth rib as well as the right mandible, and an enhancing mass in the left cerebellum. The data of radiography were highly suggestive of Langerhans' cell lineage. The presence of large CD1a-positive mononuclear cells associated with inflammatory cells in peripheral blood smear and bone marrow aspirate further confirmed the diagnosis. In addition, expressions of S100, CD25, CD68, CD80, CD86, and Fas ligand were identified on these cells by immunocytochemical staining. The results indicate that although these cells are activated Langerhans' cells, progression of the disease and the bone destruction could be mediated by the overt FasL expression of the cells.

Sinus histiocytosis presenting as bilateral epibulbar masses

PURPOSE

To report a case of sinus histiocytosis presenting as multiple, bilateral epibulbar masses.

METHODS

We examined a 4-year-old child with a 2-month history of gradually enlarging, salmon-colored epibulbar masses. Excisional biopsies and a systemic evaluation were performed.

RESULTS

Systemic evaluation was normal; no lymphadenopathy was documented. Histopathologic evaluation disclosed features consistent with sinus histiocytosis. Flow cytometry and gene rearrangement studies confirmed the benign nature of the disease. No tumor recurrence was noted.

CONCLUSION

Sinus histiocytosis may present as isolated epibulbar masses that may be treated with surgical excision.

Langerhans' cell histiocytosis and juvenile xanthogranuloma of the orbit. Clinicopathologic, CT, and MR imaging features

The clinical, radiologic, and histopathologic features of two main disorders of the orbit are discussed. Group I, Langerhans cell histiocytosis (histiocytosis X, Class I), is caused by proliferation of X histiocytic Langerhans' cells. Group II is juvenile xanthogranuloma, and Class II is related to the proliferation of non-X histiocytic (monocyte-macrophage) cells. The two diseases are of unknown cause and differ in their clinical, radiologic, and histopathologic features.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease)

Sinus histiocytosis with massive lymphadenopathy (SHML) is a distinct clinicopathological entity described by Rosai and Dorfman and differentiated by other childhood histiocytoses by its distinct characteristics. This is a rare pathology and should be kept in mind for differential diagnosis of neck masses, especially in childhood. In this article a case with SHML is presented and clinical features of the disease given.

Langerhans cell histiocytosis research. Past, present, and future

This article reviews the various investigative events that led to the endorsement of the term Langerhans cell histiocytosis for the various clinicopathologic conditions previously called Hand-Schüller-Christian disease, Abt-Letterer-Siwe disease, eosinophilic granuloma of bone, and histiocytosis X. The different denominations reflect the changing conceptual approaches to the so-called reticuloendothelial system and the successive acquisition of new ultrastructural and immunocytochemical data.

Unusual expression of S-100 protein in histiocytic neoplasms

Twenty-nine cases of histiocytic neoplasms, some resembling juvenile xanthogranuloma (JXG) and others resembling reticulohistiocytoma (RH), were evaluated. Immunohistochemical stains were performed. In this series, seven cases were identified that expressed S-100 protein positive cells. The S-100 positive cells were predominantly large mononuclear and multinucleated histiocytes with eosinophilic cytoplasm, but also in some cases xanthomatous cells and Touton giant cells. These cells also expressed a positive reaction for vimentin, KP-1, and Factor XIIIa. There was no reactivity observed for monoclonal antibody 010(CD1a). A positive reaction for S-100 protein is conventionally accepted as a useful differentiating feature between histiocytosis X and non-X histiocytosis such as JXG and RH. The conflicting results of the immunohistochemical stains in the lesions we studied could be potential pitfalls in diagnosing histiocytic neoplasms.

Langerhans cell histiocytosis with orbital involvement

PURPOSE

To review three cases of Langerhans cell histiocytosis with orbital involvement that represent a significantly excessive incidence of this rare disease in one community. Current diagnostic criteria and therapeutic modalities related to Langerhans cell histiocytosis are reviewed.

METHODS

Case reports. We present clinical, radiologic, histopathologic, and epidemiologic information on three patients with Langerhans cell histiocytosis.

RESULTS

All three children, born within 18 months of one another, manifested rapidly progressive unilateral proptosis at age 2 years. By computed tomography, all had moderately enhancing lesions with involvement of the sphenoid bone and lateral orbit as well as the temporal lobe of the brain. All patients were treated with a combination of vincristine and prednisone, with variable resolution of their lesions. The occurrence of three cases in children born in Nogales, Arizona/ Mexico, suggests an incidence rate of 40 per million, which is approximately 26 times the expected rate (P = .0001).

CONCLUSIONS

The extraordinarily high incidence and the concentration of cases in both time and space of this cluster implies that Langerhans cell histiocytosis may be a sentinel disease for unusual environmental exposures.

Ocular involvement in familial erythrophagocytic lymphohistiocytosis

BACKGROUND

Familial erythrophagocytic lymphohistiocytosis (FEL), a rare, rapidly fatal childhood disorder, is characterized by intermittent fevers, hepatosplenomegaly, cytopenia, hypercytokinemia and lymphohistiocytic infiltration with erythrophagocytosis involving multiple organs. We report the clinical and histological features of two infants with FEL and emphasize the ocular findings.

METHODS

Microscopic examination of formalin-fixed, paraffin-embedded autopsy material was performed. Immunohistochemical studies were performed in case 1.

RESULTS

The first patient presented with clinical and laboratory features and a family history consistent with FEL, and a liver biopsy revealed a lymphohistiocytic infiltrate with erythrophagocytosis consistent with FEL. A deceased brother had been diagnosed with FEL. Autopsy showed widely disseminated lymphohistiocytic infiltrates affecting the liver, spleen, bone marrow, lungs, kidneys and brain. Histologic examination of both eyes disclosed a prominent lymphohistiocytic infiltrate of the optic nerve with destruction of nerve fiber bundles as well as milder infiltrates in the choroid, scleral canals, perineural areas in the orbit and the optic nerve head perivascularly. The second patient also had the typical clinical, laboratory and autopsy findings with similar involvement of most organs, including extensive infiltration of the spleen and bone marrow. Histologic examination of one eye revealed marked lymphohistiocytic infiltration of the entire choroid as well as milder infiltration in the trabecular meshwork, iris, ciliary body, optic nerve, meninges and around the central retinal vein in the optic nerve.

CONCLUSION

The findings of this study further define the ocular pathologic features of FEL, which are a part of a generalized, multiorgan disseminated disease.

Fine-needle aspiration cytology of sinus histiocytosis with massive lymphadenopathy: a case report

Cytological findings of sinus histiocytosis with massive lymphadenopathy (SHML), involving bilateral cervical lymph nodes of a 12-yr-old boy, are presented here. A striking feature was the presence of large histiocytes with abundant pale cytoplasm containing well-preserved lymphocytes, plasma cells, and occasional neutrophils, scattered in a background of reactive lymphoid cells. Subsequent open biopsy of the lymph node mass confirmed the cytologic findings. Cytologic features of SHML are virtually diagnostic and can negate the need for an open biopsy in most cases.

Cytomorphology of some uncommon tumors of childhood and adolescence

With the advent of newer adjuvant chemotherapeutic regimes resulting in dramatic improvement in survival, it is mandatory to obtain quick correct diagnosis, which is provided by fine needle aspiration cytology (FNAC). Cytology of childhood tumors was studied to find any distinguishing features, which would help in arriving at a diagnosis. Cytomorphology of 386 childhood and adolescent (0-19 years) tumors diagnosed between 1984 and 1993 were studied. Lipoma was the commonest benign tumor in 0-14 years age group. Fibroadenoma of the breast was the common benign tumor in adolescent (10-19 yrs) girls and pleomorphic adenoma in adolescent (15-19 yrs) boys. Wilms' tumor was the most frequent solid malignant tumor in preschool children and Hodgkin lymphoma, mixed cellularity in the school going age (5-19 yrs). Malignant tumors were more frequent (199). In addition, some rare malignancies like hepatoblastoma, meningioma, ganglioneuroblastoma, adrenocortical carcinoma, clear cell sarcoma kidney and malignant histiocytosis were diagnosed. The cytological features and the differential diagnoses are discussed. It is possible to diagnose these uncommon tumors if particular attention is paid to the distinguishing cytomorphological features in correlation with clinicoradiological findings and cytochemistry.

Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years

We summarize our experience with 238 cases of Langerhans cell granulomatosis (LCG), 198 of whom were followed for a median period of 10.5 years. Our patients did well unless overtreated, and no deaths were attributed to the disorder itself. The disease may appear in unifocal or multifocal form, and treatment is based on this fact. Virtually all patients recovered completely except for occasional residual orthopedic problems or residual diabetes insipidus. Several of the patients underwent subsequent pregnancies without difficulty. The granulomas primarily occur in bone, but lung, skin, and lymph nodal involvement is not uncommon. Involvement of thyroid, thymus, and other sites is rare. The hallmark of the disease is the accumulation of Langerhans cells (LCs). We review the pathology of LCG by histology, electron microscopy, and immunolabeling. LCs originally were identified in squamous epithelium, but these cells are part of the widespread system of dendritic cells. The latter cells, which arise from CD34+ progenitors, are specialized and efficient antigen-presenting cells for T-cell-mediated immunity. In LCG, however, the major associated cells are not T cells, but mature eosinophils: hence the original name eosinophilic granuloma. Confusion about terminology has been based upon the scanty and rather crude pathology reports in the original literature. The term histiocytosis X was meant to cover a spectrum of three diseases--eosinophilic granuloma, Hand-Schüller-Christian disease (HSC), and Letterer-Siwe disease (LS)--but HSC and LS have no basis in pathology and hence the terms are meaningless. The term HSC has become a synonym for multifocal eosinophilic granuloma (LCG). The term LS has been used in reporting a number of benign, malignant, or unknown conditions. We prefer the term LCG to avoid confusion with the term histiocytosis X because there is evidence that the LC is not a member of the mononuclear phagocyte system and hence not a tissue macrophage, and because the use of the term "histiocyte" has become a convenience in much of the literature when reporting incompletely understood diseases.

Langerhans' cell histiocytosis (histiocytosis X) of bone. A clinicopathologic analysis of 263 pediatric and adult cases

BACKGROUND

Langerhans' cell histiocytosis (LCH) of bone is a disorder of histiocytic proliferation with variable and often unpredictable behavior.

METHOD

The authors evaluated the clinical and pathologic features of 263 patients (172 children, 91 adults) with biopsy-proven LCH examined during an 80-year period at the Mayo Clinic. Only patients with bone involvement pathologically and/or radiographically were included in the study. Clinical follow-up was available for 245 patients and ranged from 3 months to 50 years (mean, 12 years; median, 10 years). Chi-square tests were used to determine associations between age, gender, extent of osseous involvement, visceral disease, and pathologic features. Survival analyses were performed by univariate and multivariate Cox regression methods.

RESULTS

Age at presentation ranged from 2 months to 71 years with a clear predominance in children. The most common presenting complaint was pain, often worse at night. The skull was the most frequent osseous site in children and adults. Diabetes insipidus was documented in 40 patients. Forty-four children developed skeletal recurrence and/or new bone lesions, 19 of whom had diabetes insipidus. Fourteen children and 3 adults died either directly or indirectly from LCH. One adult patient developed systemic amyloidosis. All but two of these pediatric patients were 3 years of age or younger at presentation. All children with hepatosplenomegaly (7 patients) and/or thrombocytopenia (9 patients) died. Nine of the 14 children who died presented initially with three or more bone lesions.

CONCLUSIONS

The clinical behavior of LCH of bone is often unpredictable; however, young age at diagnosis, hepatosplenomegaly, thrombocytopenia, and polyostotic (> or = 3 bones involved) disease are associated with a poor prognosis (P < 0.005). Recrudescence in children, but not in adults, strongly correlates with the presence of diabetes insipidus (P < 0.0005).

An unusual form of localized papulonodular cutaneous histiocytosis in a 6-month-old boy

We report a 6-month-old boy with an unusual form of cutaneous histiocytosis. The lesions were noticed shortly after birth, and there was no evidence of systemic disease. This histiocytic disorder could not be classified according to the Histiocyte Society classification, and was therefore designated an 'unclassified' group II histiocytic disorder. The clinical picture was characterized by dark-red papulonodules with a tendency to coalesce into plaques. Histologically, the infiltrate was characterized by non-epidermotropic histiocytes showing varying degrees of differentiation, eosinophils and lymphocytes, and by the absence of foamy cells and Touton giant cells. As a most conspicuous feature, electron microscopic examination revealed laminated dense bodies, whereas Birbeck granules and comma-shaped bodies were absent. This further distinguished this uncommon variant from the well-known class II histiocytoses. During a 6-month follow-up period all the lesions showed marked regression.

Benign juvenile xanthogranuloma of the larynx

Benign juvenile xanthogranuloma is a normolipaemic, self-limiting condition usually presenting with cutaneous, orbital or occasionally with visceral lesions. It is one type of histiocytosis, a term referring to a group of non-inflammatory, proliferative disorders of the monocyte/macrophage and dendritic cell systems [7]. We report a case of benign juvenile xanthogranuloma occurring in the larynx, a location not previously described.

Langerhans' cell histiocytosis of the eyelid

Images

Case report: juvenile xanthogranuloma with pulmonary, subcutaneous and hepatic involvement

Juvenile xanthogranuloma is a rare benign condition in which lesions are usually confined to the skin. We describe a case with additional pulmonary, hepatic and subcutaneous lesions.

Immunohistochemical detection of granulocyte/macrophage colony-stimulating factor in Langerhans' cell histiocytosis

Granulocyte/macrophage-colony stimulating factor (GM-CSF) induces in vitro activation of Langerhans' cells. The association of GM-CSF and tumour necrosis factor alpha (TNF alpha) induces the differentiation of Langerhans' cells from CD34 positive haematopoietic progenitors. Intradermal administration of recombinant GM-CSF is associated with local accumulation of Langerhans' cells. We investigated the presence of GM-CSF in tissue samples of 10 patients with Langerhans' cell histiocytosis. Four patients had skin involvement, three had bone and three had diffuse disease. Eight normal skin samples were analysed as controls. Immunohistochemistry was performed on frozen tissue samples with two specific monoclonal antibodies directed against two different epitopes of GM-CSF. We detected GM-CSF in all the histiocytosis tissue samples. The GM-CSF was detected within the cytoplasm of all the tumoral Langerhans' cells. We did not find GM-CSF in any other cell type. These results suggest that GM-CSF may be implicated in the pathogenesis of Langerhans' cell histiocytosis.

Sinus histiocytosis (Rosai-Dorfman disease) clinically limited to the skin. An immunohistochemical and ultrastructural study

A case study of sinus histiocytosis of Rosai-Dorfman (SH) clinically limited to the skin is presented with immunohistochemical study of the infiltrate, in both paraffin and cryostat sections. Factor XIIIa, a dendrocyte marker, was demonstrated in the cytoplasm of histiocytes. This feature had not been previously reported in this disease. In addition, the cells expressed S100 protein, CD4, CD1a, CD68, and CD11c. This immunophenotyping study suggests that SH could affect the antigen-presenting activity of Factor XIIIa cells, i.e., the skin dermal dendrocyte.

Multisystem Langerhans' cell histiocytosis with pancreatic involvement

Langerhans' cell histiocytosis, a rare disorder of unknown cause affecting both children and adults, can affect many different organs and present to a wide range of medical specialties. An infant with fatal multisystem Langerhans' cell histiocytosis in whom the pancreas and the intestine were extensively affected is reported. The direct pancreatic involvement by this disease has not previously been described.

Langerhans cell histiocytosis of the vulva

A case of an 82-year-old woman with an ulcerated vulvar nodule suspected to be malignant is presented. The lesion turned out to be the primary localization of a generalized Langerhans cell histiocytosis. Six cases with a similar presentation have been reported previously and are reviewed.